| NPI | 1669953774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 39259) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60884780) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60884780) | |
| Enumeration Date | 2018-08-27 |
| Last Update Date | 2023-05-26 |